Editorial Comment on the Fourth Annual I-MESH Symposium: Communicating Complexity in Mental and Social Health

Musculoskeletal illness is often far more complex than assumed. Illness is always deeply intertwined with mental and social health, both of which have notable associations with incapability and discomfort [1, 3, 5]. The International Consortium for Musculoskeletal Mental and Social Health (I-MESH) was established to enhance the evidence on these topics and improve the delivery of healthcare for individuals with musculoskeletal illness [12]. This month, we are pleased to present the selected proceedings from our fourth annual I-MESH Symposium in Clinical Orthopaedics and Related Research®. To kick things off, we want to address an often-overlooked component of effective musculoskeletal care: how we communicate about mental and social health.

Clear and productive communication about mental and social health can facilitate effective, patient-centered musculoskeletal care. Many clinicians recognize this but feel they lack the training or confidence to effectively and compassionately discuss these topics [2, 7, 11]. The result is not only unmet mental and social health needs, but also potential harm, including feelings of confusion, blame, stigma, distrust, and dissatisfaction among patients.

The Problem With the Words We Use

The words we use to discuss mental and social health must be accurate and easy for patients to understand. At the same time, they must be comforting, nonstigmatizing, and consistent across musculoskeletal practitioners to avoid confusion.

Often, the words we use meet none of these criteria.

Many mental and social health terms used in clinical musculoskeletal care today were never meant to be used with patients [10]. Terms like “pain catastrophizing,” “fear avoidance,” and “kinesiophobia” were developed by researchers to define and study cognitive constructs. For patients, these words may be unfamiliar at best and disagreeable or stigmatizing at worst [4]. But simplifying technical terms to make them more understandable for patients can also have drawbacks. Terms like a “blown disc” or “bone on bone,” while illustrative, are imprecise and can cause unwarranted distress rather than validation and comfort for patients [9].

A Communication Evolution

An important first step toward better communication on this topic—highlighted as a top clinical priority in a recent Delphi study by I-MESH [8]—is to develop clear and accurate terminology that conveys key concepts relevant to musculoskeletal illness. This is no easy task. However, we have seen success in similar efforts. The field of pain neuroscience education has effectively distilled complex scientific principles of the pain experience into clear, patient-centered language using metaphors and imagery [6]. We believe a similar evolution is long overdue for topics related to mental and social health.

We propose describing mental health to patients as “mindsets,” which are shaped by how we think (cognitions) and feel (emotions) (Fig. 1). Both thoughts and feelings can be either helpful or unhelpful in managing musculoskeletal illness.

Fig. 1.

Proposed terminology to facilitate conversations regarding mental and social health in musculoskeletal care. © Arotin Hartounian

Helpful thoughts are characterized by critical reasoning, problem solving, and flexibility (the ability and willingness to change beliefs based on new information). Examples include acceptance and self-efficacy or confidence in one’s ability to manage their condition. Unhelpful thoughts encompass cognitive errors and misconceptions related to pain or injury. Concepts like pain catastrophizing and fear avoidance beliefs would fit this category. Many unhelpful thoughts are rigid and automatic, arising from mental shortcuts that are often hard-wired and reinforced through past experiences. Sometimes, these thoughts can be protective—such as fear of potentially dangerous activities after an acute injury—but often, these thoughts can hamper recovery, such as when people seeking care for low back pain begin to fear any activity.

Feelings are influenced by experiences, body sensations, and behavioral responses. Helpful feelings include optimism and hope while unhelpful feelings include despair and worry. Feelings can be specific to bodily sensations or more general. Overwhelming apprehension and rumination (the inability to divert one’s focus away from pain) are particularly unhealthy.

Although thoughts and feelings are distinct concepts, they are closely linked. Explaining this connection to patients in simple terms can help them understand how thoughts and feelings impact their illness and behaviors. For example, we can explain that unhelpful thoughts (such as preparing for the worst when experiencing pain) can lead to feelings (such as pain-related anxiety) and behaviors (like activity avoidance) that can make pain more intense and decrease capability. Conversely, helpful thoughts can promote adaptive feelings and behaviors that can reduce the impact of injury, disease, and aging.

Social health is better understood as one’s circumstances. Circumstances are influenced by various factors, such as a person’s social role or identity (for example, that of spouse, caretaker, or community leader), and relationships with others that drive feelings of support, isolation, or conflict. The stability and security of the environment in which people live and work also influences circumstances, manifesting in needs related to transportation, housing, food, healthcare, and finances.

As with discussions around mindsets, effective communication about circumstances should employ patient-centered and nonstigmatizing language that simplifies complex concepts and normalizes discussions about needs. Using plain language, such as referring to “having enough food to eat” instead of “food insecurity,” can make these conversations more accessible.

Moving the Right Words Into Practice

Changing terminology is necessary, but not sufficient on its own to improve communication. We must also change how these concepts are embedded and delivered in clinical discussions (Table 1). Additionally, we offer the following suggestions to enhance communication on these topics:

1. Frame questions about mindset and circumstances as a routine part of care for all patients, especially since patients might not expect these topics to come up in routine musculoskeletal care. Explaining the rationale behind certain questions before they are asked—such as how housing situations impact musculoskeletal illness—can help patients see these inquiries as relevant, standard, and nonjudgmental.

2. Empathy and validation make patients feel heard and understood. Be sure to summarize and legitimize a patient’s experience. A phrase like, “It sounds like you're dealing with a lot,” acknowledges their struggles and builds trust, which grows when people feel heard and understood. Highlighting patients’ strengths and resilience, such as their ability to manage challenges independently, reinforces a supportive environment. Collaborative language like, “let's work together to find solutions,” empowers patients and fosters a sense of partnership.

3. Sharing anonymized patient stories to illustrate the positive impact of addressing mental and social health needs can make these concepts more relatable and underscore their importance.

4. Remember that suggesting a new way of thinking about symptoms negates a person’s lived experience, which is always a threat to the relationship. Helping a patient establish a healthier narrative about illness is a gradual, incremental process that is rooted in the trust built by appreciating and normalizing that patient’s experience. Reinforce that mindsets and circumstances do not cause symptoms but can make symptoms more or less intense.

Table 1.

Examples of how to initiate discussions about mindsets and circumstances in musculoskeletal care

	Example language
Mindsets
Unhelpful emotions	-What stops you from doing the things you enjoy? -What type of relationship do you notice between your symptoms and your stress or worry?
Helpful emotions	-What helps you stay positive when you’re dealing with pain? -Are there specific goals or milestones that motivate you to keep going when your symptoms are challenging?
Unhelpful thoughts	-What activities do you avoid because you're afraid they might cause you more pain? -When you think about your symptoms, what kinds of thoughts do you have? -When you look 6 months into the future, what do you think your symptoms will be like?
Helpful thoughts	-What strategies have you tried to manage your symptoms? What worked well and didn’t work well for you? -Tell me about your outlook on your recovery.
Circumstances
Security and stability	-Can you tell me about your current living situation? -Do you have consistent access to enough food for you and your family? -Do you have reliable transportation to get to your appointments, work, or other important places? -Can you tell me about any times you have felt threatened or unsafe in your current living situation?
Social relationships	-Have you experienced any issues in your relationships that are affecting your well-being? -Are you feeling supported? Who do you usually turn to for support when you're feeling down or need help? -Have you felt isolated or lonely recently?
Social role and identity	-How have your symptoms impacted your role at home or work? -Has your condition changed the way others see or treat you? -Do you feel that your condition has affected how you see yourself or your identity?

Communicating complex topics, especially those related to mental and social health in musculoskeletal illness, is complex within itself. While we cannot fully address all nuances of communication here, we can advocate for the use of clear, consistent, and compassionate terms as the first important step toward improving care for musculoskeletal conditions.

We hope you will find these proceedings informative and inspiring. If you are interested in joining our group, visit www.i-mesh.org.